Bacterial vaginosis (BV) is treated with prescription antibiotics, and most cases clear up within a week. It’s the most common vaginal infection in women of reproductive age, and while it sometimes resolves on its own, antibiotics are the most reliable way to eliminate it. The tricky part isn’t the initial treatment: up to 66% of women experience a recurrence within a year, so knowing how to treat it and how to keep it from coming back are equally important.
How BV Gets Diagnosed
BV shares symptoms with yeast infections and other conditions, so getting the right diagnosis matters before you start any treatment. The hallmark signs are a thin, grayish-white discharge and a fishy odor that often becomes stronger after sex. Some women also notice mild itching or burning, though many have no noticeable symptoms at all.
A clinician typically diagnoses BV by checking for a few specific markers: vaginal pH above 4.5, the presence of “clue cells” (vaginal cells coated in bacteria) under a microscope, a fishy smell when a chemical solution is added to a discharge sample, and the characteristic thin discharge. Meeting three of these four criteria confirms BV. Some providers use a lab-based scoring method that examines the balance of bacterial types in a vaginal swab, which can be more precise.
First-Line Antibiotic Treatments
The CDC recommends three main options, all equally effective as first choices:
- Oral metronidazole: taken twice daily for 7 days. This is the most widely prescribed option.
- Metronidazole vaginal gel: applied once daily for 5 days. Some women prefer this because it targets the area directly with fewer systemic side effects.
- Clindamycin vaginal cream: applied at bedtime for 7 days.
If you can’t tolerate these or prefer a shorter course, alternative options exist. One is a related oral antibiotic taken once daily for just 2 to 5 days. There’s also a single-dose oral treatment (secnidazole) that you take just once. A meta-analysis found that this single-dose approach works about as well as the standard 7-day metronidazole course, making it a convenient choice if you’re looking for the simplest regimen.
Avoid alcohol while taking oral metronidazole or similar antibiotics in that class, as it can cause severe nausea and vomiting. If you’re using the vaginal cream form of clindamycin, be aware that it can weaken latex condoms and diaphragms for up to 72 hours after use.
What About Over-the-Counter Products?
You’ll find lactic acid gels and vaginal pH-balancing products marketed for BV at most pharmacies. The idea behind them is straightforward: BV raises vaginal pH, so lowering it back to normal should help restore healthy bacteria. The clinical reality is more mixed.
Results from randomized trials vary widely. One small study found lactic acid gel performed comparably to metronidazole immediately after treatment, with about 77% of women in both groups clearing BV criteria. But other trials showed much weaker results. In one, only 23% of women using a lactic acid product were cured after a week, compared with 88% on metronidazole. By one month, cure rates in the lactic acid group dropped to just 8%. Importantly, studies have also found that these products don’t significantly change the underlying vaginal bacterial community, which is what needs to shift for BV to truly resolve.
The bottom line: lactic acid gels may offer mild symptom relief, but there’s not enough high-quality evidence to recommend them as a standalone BV treatment.
Home Remedies: What Works and What Doesn’t
Apple cider vinegar baths are one of the most commonly searched home remedies for BV. The logic seems sound since the acetic and lactic acids could theoretically lower vaginal pH. But no studies have directly tested apple cider vinegar on BV, and researchers have noted that simply lowering pH may not be enough to resolve the infection on its own. An ACV bath is unlikely to cause harm, but it’s also unlikely to clear BV.
Boric acid vaginal suppositories are another popular option, particularly for recurrent BV. Some clinicians do recommend boric acid as an add-on therapy alongside antibiotics, but the evidence supporting it as a standalone cure is limited. If you’re considering boric acid, use it only as a vaginal suppository and never take it orally, as it is toxic when swallowed.
Probiotics for Prevention
Probiotics show more promise for preventing BV from returning than for treating an active infection. A clinical trial published in the New England Journal of Medicine tested a vaginal probiotic containing Lactobacillus crispatus in 228 women who had just finished standard antibiotic treatment. Women who used the probiotic vaginally twice per week for 11 weeks had a 30% recurrence rate by week 12, compared with 45% in the placebo group.
That’s a meaningful difference, though not a guarantee. The probiotic used in this trial (Lactin-V) is a specific strain delivered vaginally, not a generic oral probiotic capsule from the supplement aisle. Oral probiotics marketed for vaginal health haven’t shown the same level of evidence. If you’re dealing with recurrent BV, ask your provider specifically about vaginal Lactobacillus crispatus products.
Why BV Keeps Coming Back
Recurrence is the most frustrating aspect of BV. That 66% recurrence rate within a year, reported by the American College of Obstetricians and Gynecologists, means more than half of women who successfully treat BV will deal with it again. Several factors drive this pattern.
Sexual activity plays a significant role. Semen is alkaline, which temporarily raises vaginal pH after unprotected sex. Lubricants, condoms, and shared sex toys can also introduce bacteria or shift the vaginal environment. In a significant shift, ACOG now recommends concurrent treatment of male sexual partners for women with recurrent BV. This is a new recommendation, reflecting growing evidence that BV-associated bacteria can be harbored by male partners and reintroduced during sex.
Douching is one of the strongest risk factors for both initial BV and recurrence. It strips away protective Lactobacillus bacteria and disrupts vaginal pH. Scented soaps, sprays, pads, and tampons can have a similar effect. The vagina is self-cleaning, and warm water alone is all that’s needed for external washing.
Habits That Protect Your Vaginal pH
Keeping your vaginal environment stable is the best long-term strategy against BV. A few specific habits make a real difference:
- Skip all scented products near your vagina, including scented pads, tampons, sprays, and soaps.
- Change tampons and pads every few hours rather than wearing them for extended periods.
- Use condoms or dental dams to prevent your partner’s bodily fluids from altering your pH.
- Change out of wet or sweaty clothes promptly, especially after swimming or working out.
- Never douche. This is the single most impactful thing you can stop doing if you currently do it.
If you’ve had BV more than three times in a year, your provider may recommend a longer-term maintenance regimen with a low-dose vaginal antibiotic gel used once or twice weekly for several months. Combined with partner treatment and the lifestyle changes above, this approach gives you the best chance of breaking the cycle.